Faculty Bibliography

Hinged prostheses have been increasingly utilized in complex and revision total knee arthroplasty (TKA) cases requiring additional mechanical support and global stability. However, there is limited data detailing the outcomes of modern hinge designs in these procedures. The aim of this study is to report a minimum 2-year functional outcomes and survivorship of a novel-guided motion-hinged knee TKA system. A multicenter, retrospective cohort study was conducted on consecutive TKA patients between March 2013 and August 2017 with a novel-guided motion-hinged knee system. Demographics, change in range of motion (ΔROM), quality metrics, and implant survivorship were collected with a minimum of 2-year follow-up. Implant survival was analyzed by using the Kaplan-Meier method. Overall, 147 hinged knee cases (18 complex primaries and 129 revisions) were identified with an average follow-up duration of 3.8 ± 1.2 years. Patients presented with an average of 2.4 ± 1.6 prior knee surgeries, and 51 (34.7%) had a history of knee infections. The ROM improved postoperatively: Δ extension = 2 ± 1 degrees, Δflexion = 7 ± 3 degrees, Δtotal ROM = 9 ± 4 degrees. Kaplan-Meier survivorship analysis for implant revision at 2- and 5-year follow-up showed a survival rate of 100 and 98.5% (95% confidence interval: 94.3-99.6%), respectively, with one patient undergoing two-stage revision for infection and another undergoing femoral revision for aseptic loosening. Survivorship for aseptic all-cause reoperation at 2- and 5-year follow-up was 93.2% (87.7-96.3%) and 88.2% (80.0-93.2%), respectively. Fourteen patients underwent aseptic reoperation (patellar complications: n = 7 [4.8%]; instability: n = 5 [3.4%]; tuberosity fixation: n = 1 [0.7%]; extensor mechanism failure: n = 1 [1.1%]). Survivorship for all-cause reoperation at 2- and 5-year follow-up were 85% (78.2-90.0%) and 77.7% (68.8-84.3%), respectively. Fifteen patients underwent reoperation for infection (DAIR: n = 14 (9.5%); two-stage revision: n = 1 [0.7%]). Despite some reoperations, this guided-motion hinged-knee TKA system demonstrates excellent survivorship for component revision compared to other modern hinged knee implants reported in the literature. Patients also displayed an improvement in knee ROM at their latest follow-up.

PURPOSE/OBJECTIVE:The clinical impact of postoperative venous thromboembolism (VTE) following total joint arthroplasty (TJA) remains unclear. In this study, we evaluate the effect of VTE following TJA on postoperative outcomes including discharge disposition, readmission rates, and revision rates. METHODS:We retrospectively reviewed all patients over the age of 18 who underwent primary, elective THA or TKA between 2013 and 2020. Patients were stratified into two cohorts based on whether or not they had a VTE following their procedure. Baseline patient demographics and clinical outcomes such as readmissions and revisions were collected. Propensity score matching was performed to limit significant demographic differences, while independent sample t-tests and Pearson's chi-squared test were used to compare outcomes of interest between the groups. RESULTS:, p = 0.032). All other patient demographics were similar. Compared to the non-VTE cohort, the VTE cohort was less likely to be discharged home (66.1% vs 80.7%; p = 0.021), had a higher rate of 90-day all-cause readmissions (27.5% vs 9.2%, p = 0.001), and a higher two-year revision rate (11.0% vs 0.9%, p = 0.003). CONCLUSION/CONCLUSIONS:Patients with postoperative VTE were less likely to be discharged home and had higher 90-day readmission and two-year revision rates. Therefore, mitigating perioperative risk factors, initiating appropriate long-term anticoagulation, and maintaining close follow-up for patients with postoperative VTE may play significant roles in decreasing hospital costs and the economic burden to the healthcare system. LEVEL OF EVIDENCE III/UNASSIGNED:Retrospective Cohort Study.

INTRODUCTION/BACKGROUND:Although tourniquet use in primary total knee arthroplasty (TKA) has been widely studied, the outcomes associated with tourniquet use in revision TKA (rTKA) remains relatively unexplored. This study investigates surgical outcomes and patient satisfaction in association with tourniquet use during aseptic rTKA. METHODS:We retrospectively reviewed all patients who underwent rTKA for aseptic causes at our institution from 2011-2020. Patients were separated into two cohorts based on tourniquet inflation during the procedure. Outcomes of interest included estimated blood loss (EBL), change in hemoglobin (Hb), surgical time, length-of-stay (LOS), reoperation rate, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS,JR) scores. RESULTS:Of the 1,212 patients included, 1,007 (83%) underwent aseptic rTKA with the use of a tourniquet and 205 (17%) without the use of a tourniquet. The mean tourniquet inflation time was 93.0 minutes (SD:33.3 minutes). Blood loss was significantly less for patients in the tourniquet cohort as measured through EBL(224.1vs.325.1 mL,p<0.001) and change in preoperative to postoperative Hb(1.75vs.2.04 g/dL,p<0.001). There were no statistical differences in surgical time(p=0.267) and LOS(p=0.206) between the two groups. The reoperation rate was significantly greater for patients who did not have a tourniquet utilized (20.5%vs.15.0%,p=0.038). Delta improvement in KOOS,JR scores from baseline to 3-months postoperatively did not statistically differ between the two cohorts (p=0.560). CONCLUSION/CONCLUSIONS:While delta improvements in KOOS,JR scores were similar for both cohorts, patients who did not have a tourniquet inflated during aseptic rTKA had increased blood loss and were more likely to undergo subsequent reoperation compared to patients who did.

INTRODUCTION/BACKGROUND:Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged the day of surgery. This study compares outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD. METHODS:We retrospectively reviewed all patients who were SDD following TJA from 2015-2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups. RESULTS:Of the 1,778 patients included, 1,384(78%) completed the SDD TJA program and 394(22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. Surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39vs.87.29 minutes; p<0.001). Discharge disposition(p=0.999), 90-day ED-visit (p=0.476), 90-day all-cause readmissions(p=0.999), 90-day all-cause revisions(p=0.563), as well as HOOS,JR and KOOS,JR scores at all time-points did not significantly differ. CONCLUSION/CONCLUSIONS:Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients that are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and experience with value-based care.

BACKGROUND:In order to better understand the clinical benefits of total knee arthroplasty (TKA) and improve the interpretability of the Forgotten Joint Score (FJS-12), the establishment of a meaningful change in score is necessary. The purpose of this study is to determine the threshold of the FJS-12 for detecting the patient acceptable symptom state (PASS) following primary TKA. METHODS:percentile of the cumulative percentage curve of patients who had the KOOS, JR score difference larger than the cut-off value. RESULTS:percentile approach was 77.1 (95% CI [73.9, 81.5]). CONCLUSION/CONCLUSIONS:percentile approaches, respectively. These values can be used to assess the successful achievement of a forgotten joint. LEVEL III EVIDENCE/METHODS:Retrospective Cohort Study.

INTRODUCTION/BACKGROUND:Medicaid expansion has allowed more patients to undergo total hip arthroplasty (THA). Given the continued focus on the opioid epidemic, we sought to determine whether patients with Medicaid insurance differed in their postoperative pain and narcotic requirements compared with privately or Medicare-insured patients. METHODS:A single-institution database was used to identify adult patients who underwent elective THA between 2016 and 2019. Patients in the Medicaid group received Medicaid insurance, while the non-Medicaid group was insured commercially or through Medicare. Subgroup analysis was done, separating the private pay from Medicare patients. RESULTS:A total of 5,845 cases were identified: 326 Medicaid (5.6%) and 5,519 non-Medicaid (94.4%). Two thousand six hundred thirty-five of the non-Medicaid group were insured by private payors. Medicaid patients were younger (56.1 versus 63.28 versus 57.4 years; P < 0.001, P < 0.05), less likely to be White (39.1% versus 78.2% versus 76.2%; P < 0.001), and more likely to be active smokers (21.6% versus 8.8% versus 10.5%; P < 0.001). Surgical time (113 versus 96 versus 98 mins; P < 0.001) and length of stay (2.7 versus 1.7 versus 1.4 days; P < 0.001) were longer for Medicaid patients, with lower home discharge (86.5% versus 91.8% versus 97.2%; P < 0.001). Total opioid consumption (178 morphine milligram equivalents [MMEs] versus 89 MME versus 82 MME; P < 0.001) and average MME/day in the first 24 hours and 24 to 48 hours (52.3 versus 44.7 versus 44.45; P < 0.001 and 73.8 versus 28.4 versus 29.8; P < 0.001) were higher for Medicaid patients. This paralleled higher pain scores (2.71 versus 2.31 versus 2.38; P < 0.001) and lower Activity Measure for Post-Acute Care scores (18.77 versus 20.98 versus 21.61; P < 0.001). CONCLUSIONS:Medicaid patients presenting for THA demonstrated worse postoperative pain and required more opioids than their non-Medicaid counterparts. This highlights the need for preoperative counseling and optimization in this at-risk population. These patients may benefit from multidisciplinary intervention to ensure that pain is controlled while mitigating the risk of continuation to long-term opioid use.

Venous thromboembolism (VTE) is a rare, but serious complication following total knee arthroplasty (TKA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81-mg aspirin (ASA) twice a day (BID) and portable IPCDs were previously prescribed to TKA patients at standard risk for VTE, but the IPCDs were discontinued and patients were treated with ASA alone going forward. The aim of this study is to determine if discontinued use of outpatient IPCDs is safe and does not increase the rate of VTE or any other related complications in patients following TKA. A retrospective review of 2,219 consecutive TKA cases was conducted, identifying patients with VTE, bleeding complications, infection, and mortality within 90 days postoperatively. Patients were divided into two cohorts. Patients in cohort one received outpatient IPCDs for a period of 14 days (control), while those in cohort two did not (ASA alone). All study patients received inpatient IPCDs and were maintained on 81-mg ASA BID for 28 days. A posthoc power analysis was performed using a noninferiority margin of 0.25 (α = 0.05; power = 80%), which showed that our sample size was fully powered for noninferiority for our reported deep vein thrombosis (DVT) rates, but not for pulmonary embolism (PE) rates. A total of 867 controls and 1,352 patients treated with ASA alone were identified. Only two control patients were diagnosed with a PE (0.23%), while one patient in the ASA alone group had DVT (0.07%). There was no statistical difference between these rates (p = 0.33). Furthermore, no differences were found in bleeding complications (p = 0.12), infection (p = 0.97), or 90-day mortality rates (p = 0.42) between both groups. The discontinued use of outpatient portable IPCDs is noninferior to outpatient IPCD use for DVT prophylaxis. Our findings suggest that this protocol change may be safe and does not increase the rate of VTE in standard risk patients undergoing TKA while using 81-mg ASA BID.

BACKGROUND:Patients who undergo total hip arthroplasty (THA) require resilience to recover and resume daily functions. Increased resilience may be an important factor for achieving improved outcomes. The purpose of this study is to examine the impact of resilience on time to discharge and on early patient-reported outcomes following primary THA. METHODS:A retrospective review of patients who underwent primary THAs and completed the Brief Resilience Scale (BRS) was conducted from 2020 to 2021 at an urban, academic hospital. Patients were separated into 3 cohorts based on BRS score: low (1-2.99), normal (3-4.30), and high (4.31-5) resilience. Demographics, participation in same-day discharge (SDD) program, length of stay (LOS), and preoperative and 3-month postoperative scores on the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) were assessed. SDD patients were excluded from LOS analysis. RESULTS:A total of 393 patients were included. Compared to low resilience patients, odds of being enrolled in SDD program were 1.49 and 3.01 times higher (P = .01) and 3-month HOOS JR scores improved by 4.7% and 11.7% (P = .03) for normal and high resilience patients, respectively. As resilience increased from low to normal to high in non-SDD patients, LOS significantly decreased (53.27 ± 51.92 vs 38.70 ± 28.03 vs 25.64 ± 14.48 hours, respectively; P = .001). CONCLUSION/CONCLUSIONS:Increased resilience is positively associated with likelihood of SDD participation or decreased LOS. Increased resilience was associated with increased HOOS JR scores at 3 months, although this did not reach the minimal clinically important difference. The BRS may be a useful tool for predicting patients who can successfully participate in SDD or predicting LOS after primary THA.